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Doctors' Notes: Stopping opioid use completely will only cause more problems

We need to prescribe opioids less often, for shorter periods, with lower doses.

Patients should not more than three to four days worth of pain medications for acute injuries or post operatively (TNS FILE PHOTO)

By Dr. Peter SelbyUniversity of Toronto

Mon., Nov. 21, 2016

Canadians have one of the highest rates of prescription opioid use in the world – five times higher than in the U.K., for example. This is a tragedy because we don’t do any better at reducing chronic pain – just at creating addiction and an epidemic of overdose death.

Many reasons have caused this, including the influence and marketing tactics of the pharmaceutical industry, the willingness of Canadian insurers to pay for drugs like OxyContin, as well as mistaken assumptions about opioids by prescribers and dispensers.

Despite this, I’m not advocating we ban certain types of prescription drugs outright. Knee-jerk decisions could leave people in pain, push those addicted to use more dangerous types of opioids, or increase use of illicit opioids such as heroin.

Instead, we need to slow down the tap of opioid supply. We need to prescribe opioids less often, for shorter periods, with lower doses. We need to look at other pain management options like physical rehab and even meditation.

What we cannot and should not do, is stop it completely.

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Here’s just one example of how the best intentions to curb the opioid epidemic can backfire if we don’t think it through: when Ontario acknowledged just how addictive OxyContin was in pill form, it removed it from public drug plans. A tamper-proof alternative, OxyNeo, was introduced, but under restricted access, leaving more potent opioids easily accessible on its public drug plan. It appears that overdose deaths have increased, in part, because of a switch by prescribers to the more potent hydromorphone and fentanyl. Plus, street drugs such as heroin and illicitly produced fentanyl have also replaced OxyContin.

A core problem is the lack of access to alternative chronic pain treatments. And that problem has deep roots in the Canadian health-care system.

Not enough doctors and pharmacists learn about pain management during their training. So it is not surprising that prescribers in both hospital and community settings are ill-prepared to manage their patients’ pain or addiction, despite their best intentions. Indeed, surveys of Canadian family physicians and pharmacists have found significant gaps in their knowledge and use of evidence-based pain management and safe opioid prescribing guidelines.

That’s why it’s important for patients to educate themselves about the dangers of prescription opioids and the alternatives to their use. Until 20 years ago, we didn’t use opioids for chronic pain, like bad backs or arthritis. We managed it with physiotherapy and other effective tools like mindfulness-based meditation — the way doctors in most other countries manage it now.

So now what?

We need to make sure the remedy does not make a bad situation worse. As a start, follow these suggestions:

Ask the prescriber for alternatives to opioids especially for the management of chronic pain.

Do not accept more than three to four days worth of pain medications for acute injuries or post operatively.

Do not start with long-acting opioids if you haven’t first tried short-acting versions of the drug.

Store opioids safely and out of reach of others, especially teenagers.

Do not alter the pills in any way (i.e. do not crush them). Doing so will alter the time-release mechanism and enhance the risk of overdose.

Do not combine with alcohol or sleeping pills

Have a naloxone overdose kit if taking opioids.

Let family members know you are taking these pills and how to use the naloxone kit

If addicted, get help as soon as possible.

If dependent, do not stop opioids suddenly-- you will experience withdrawal, including worse pain. Consult your doctor or ask for a referral to an addiction specialist.

Dr. Peter Selby is a professor in the departments of Family and Community Medicine, Psychiatry and Public Health Sciences. He is also a Clinician-Scientist in the Addictions Division and the Director of Medical Education at the Centre for Addiction and Mental Health. Doctors’ Notes is a weekly column by members of the U of T Faculty of Medicine. Email doctorsnotes.ca.

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